Scott Harding-Lister

A key function of accident and emergency departments is to identify patients who require admission to hospital or referral to specialist services. Decisions about whether to admit, observe, or discharge a patient carry significant clinical importance. Where those decisions are made incorrectly, patients may be sent home or left without appropriate review when admission or referral was required.

Failure to admit or refer patients appropriately from A&E is a common basis for clinical negligence claims and is distinct from errors in triage or diagnosis.

The role of admission and referral decisions in A&E

Admission and referral decisions are typically made after initial assessment and investigation. They involve evaluating the severity of a patient’s condition, the risks associated with discharge, and the need for further monitoring, treatment or specialist input.

Referral may be required to medical or surgical teams, such as cardiology, neurology, orthopaedics or general surgery. Admission may be required for observation, treatment or further investigation even where a diagnosis is not yet certain.

These decisions require careful clinical judgment and are influenced by protocols, risk assessment tools and clinical guidelines.

Common scenarios involving failure to admit or refer

Failures in this area can arise in a number of situations. Patients may be discharged despite abnormal observations, unresolved symptoms or ongoing pain. In other cases, patients are discharged without referral to an appropriate specialty when specialist review was indicated.

Examples include failure to admit patients with evolving neurological symptoms, failure to refer patients with suspected cardiac events, failure to admit elderly or vulnerable patients for observation, and failure to refer surgical cases for timely assessment.

In some cases, referral may be delayed rather than omitted, resulting in deterioration while the patient remains in A&E or after discharge.

Distinguishing admission failures from diagnostic errors

Failure to admit or refer is distinct from diagnostic error. A patient may be correctly diagnosed but still discharged when admission or specialist review was required.

Equally, a patient may not yet have a clear diagnosis, but admission for observation may be necessary because of the risk of deterioration. The issue in these cases is not whether the diagnosis was correct, but whether discharge was safe.

This distinction is important when assessing breach of duty and causation.

The legal test in admission and referral claims

As with all clinical negligence claims, breach of duty and causation must be established.

Breach of duty involves assessing whether a reasonably competent A&E clinician would have admitted the patient or referred them to another team in the circumstances. This assessment takes into account clinical findings, observations, investigation results and risk factors.

Expert emergency medicine and specialty evidence is required to address whether admission or referral was indicated.

Causation requires proof that failure to admit or refer caused harm or materially worsened the outcome. This may include showing that earlier admission would probably have led to closer monitoring, earlier intervention or prevention of deterioration.

Risk assessment and discharge decisions

Discharge decisions in A&E involve balancing clinical risk with practical considerations. However, risk assessment must be carried out carefully and documented properly.

Failure to identify high risk features, such as abnormal vital signs, persistent symptoms or vulnerability, may support a claim that discharge was inappropriate.

Safety netting advice does not replace the need for admission where admission is clinically indicated.

System pressures and resource constraints

Admission and referral decisions are often made in the context of significant system pressures, including bed shortages and overcrowding. While these pressures provide context, they do not remove the obligation to provide reasonable care.

From a legal perspective, the question remains whether the decision to discharge was reasonable in light of the patient’s condition and the information available at the time.

Evidence in admission and referral claims

Medical records are central to these claims. A&E notes, observation charts, investigation results and discharge summaries are used to reconstruct the decision-making process.

Evidence of referrals considered or discussed, escalation to senior clinicians, and reasons for discharge are often critical.

Expert evidence is required to assess whether the decision not to admit or refer fell below an acceptable standard and whether this caused avoidable harm.

The consequences of inappropriate discharge

Failure to admit or refer patients appropriately can lead to deterioration after discharge, delayed treatment and more severe injury. In some cases, patients re-present to A&E in a significantly worse condition or suffer catastrophic events at home.

Even where the outcome might not have been entirely avoidable, earlier admission or referral may have reduced harm or improved prognosis.

How we can help

We regularly advise individuals and families in cases involving concerns about inappropriate discharge, failure to admit or failure to refer patients from A&E.

An initial discussion allows us to review the circumstances of the A&E attendance, consider whether admission or referral should have occurred, and advise on whether further investigation is appropriate. Where a claim is pursued, we work with appropriate experts to assess whether failures in admission or referral caused avoidable harm.

If you would like to discuss concerns about care received in A&E, please contact us to arrange an initial consultation in confidence.